A randomized pilot study of a comprehensive postoperative exercise program compared with usual care following primary total hip arthroplasty in subjects less than 65 years of age: feasibility, selection of outcome measures and timing of assessment

Abstract

BackgroundTotal Hip Arthroplasty (THA) is being used more commonly in younger higher demand patients. The purpose of this randomized pilot study was to explore a) feasibility of comprehensive postoperative rehabilitation compared to usual care following primary THA in subjects <65 years, b) appropriate outcome measures including performance-based measures and c) timing of assessments.Methods21 subjects who underwent primary THA were randomized to receive a three-month out-patient rehabilitation program (Intervention) or usual postoperative care (Control). Subjects were assessed preoperatively, six-weeks postoperatively (Pre-intervention) and four and 12 months postoperatively (Post-intervention). Self-report measures were the Western Ontario McMaster Osteoarthritis Index (WOMAC) and Rand 36-Item Health Survey (RAND-36). Performance-based measures included lower extremity strength, walking speed and endurance, and gait laboratory assessment.ResultsTen Control and 11 Intervention subjects with an average age of 53.4 (SD9.3) years were randomized. All Intervention subjects completed the program without adverse effects. Although no statistically significantly results were reported, four months postoperatively, Intervention subjects had clinically important differences (CID) in strength compared with Control subjects. Walking endurance, WOMAC and RAND scores improved significantly with no CID noted between groups. Ten (48%) subjects reported a ceiling effect on the WOMAC (9 (43%) subjects on Pain; 1 (5%) subject on Function). No group CID were noted in gait measures.ConclusionsOur recommendations would be that performance-based strength measures should be considered for the primary outcome in this younger cohort. Because of the ceiling effects with WOMAC Pain, a different pain measure is indicated. Other more challenging functional performance-based tests should be considered such as a more prolonged endurance test. There is merit in one-year follow-up as strength improved after four months in both groups.

Explosive and maximal strength before and 6 months after total hip arthroplasty

“…Maximal voluntary contraction strength (hereafter referred to as MVC) has substantial impact on walking capacity and onset of dependency in activities of daily living in elderly and patient populations. Consequently, numerous studies documented the recovery of hip and knee MVC in patients before and/or after THA. Although maximum strength is one of the most common outcome measures in orthopaedic research and practice the ability to produce force rapidly (i.e., explosive strength) may be considered a more functional variable for several daily‐living activities .…”

Total hip replacement rehabilitation: current practice and telerehabilitation as a mode of service delivery

“…Rehabilitation interventions reported in the literature vary with respect to timing to commencement, frequency and duration of physiotherapy rehabilitation. Timing to commencement ranges from immediately following hospital discharge 101,102 , one to two weeks 86, 103-105 , six to twelve weeks 87,106,107 , to greater than one year post-operatively 90,92 . Frequency is most clearly reported by separating home exercise programs (HEP) from supervised physiotherapy sessions.…”

“…The only review to undertake meta-analysis was Coulter 96 86,[103][104][105] , six to twelve weeks 87,106,107 , to greater than one year postoperatively 90,92 . Frequency is most clearly reported by separating home exercise programs (HEP) from supervised physiotherapy sessions.…”

“…Supervised physiotherapy interventions are most commonly reported as two to three times weekly 86,102,106,107 ; however, some interventions report supervised physiotherapy sessions as infrequently as one per fortnight 91 . The vast majority of interventions are reported as lasting six 86,92,107 , eight 89,91,103 or twelve weeks in duration 87,90,101,102,106 . Although these studies report on timing, frequency and duration of physiotherapy interventions, the only study designed to assess the impact of any of these variables is Leibs 105 who investigated time to commencement for an aquatic therapy program.…”

“…To date, current practice is described as a control intervention in trials, with considerable variation. Some simply refer to 'usual', 'standard' or 'conventional' care 91,103,107 , others allude to range of movement, strengthening, walking and cycling 101,106 with only Suetta 102 detailing specific exercises (ankle dorsiflexion, isometric gluteals etc). Further, there is no description of how the usual / standard / conventional care was defined.…”